In October 2009, I received a call regarding a horse with a rectal tear. Little did I know, but this case would be one of the most rewarding of my career. When Sara and Sherlock arrived both had worried looks. Sherlock, a young 29 years old, had received treatment on the farm for mild colic. At that time, a defect in his rectal wall was identified and he was immediately referred to WEC&H. To avoid creating more traumas and to minimize straining during rectal examination sedation, local anesthetic and lots of lube (for Sherlock) and no glove (for me!!) was utilized. We discovered a defect the size of an NFL-regulation football in the pelvic soft tissues that communicated with the rectum through a 4 inch tear. Dr. Austin and I guided a small fiber optic camera into Sherlock's rectum and we directly viewed the defect. It was flushed, and then packed with gauze to keep manure from accumulating within. Although the tear did not appear extend into the abdomen during palpation or endoscopy, it was critical to know this for sure. If it did, Sherlock would be euthanized - treatment of a grossly contaminated abdomen in horses is generally futile. Thankfully, the belly tap showed no evidence of gross contamination (manure) or infection (bacteria).

Sara and I sat down to formulate a plan. The large size of the tear severely limited my surgical options. We elected to let the defect heal by second intention (fill with granulation tissue), then the lining of the rectum could re-establish itself. As long as the tear did not progress into the abdominal cavity, I was confident we could save Sherlock's life but suspected it might be a long and bumpy road to recovery!

In the short term we had to address the cause of the tear....Sherlock's colic. I was suspicious of impaction colic - where the manure becomes too dry to pass easily and the horse gets constipated. It was likely the tear occurred during attempts by Sherlock to defecate. I treated with fluid therapy and mineral oil administered by stomach tube. Once he began to move manure we had to prevent it from accumulating within the defect. I was concerned that packing of manure within the defect could lead to rupture of the defect into Sherlock's abdomen. We developed a "program" that would allow the defect to begin healing, while allowing Sherlock to eat and rest comfortably. The defect would be packed with gauze and we would utilize mineral oil to induce "diarrhea-like" manure that would just slide past the rectal tear and also to eliminate bulk from his diet. The wound was bound to get infected, so antibiotics were started and he received anti-inflammatories to manage his swelling and discomfort.

Sherlock was admitted into our critical care unit - his home for the next 2 ½ months. Initially he was tubed with mineral oil TWICE daily and the tear was palpated, evacuated and re-packed several times daily. All that oil and an infected rectal wound meant pretty foul manure, a fact not lost on the intern veterinarians who performed this task. Within 24 hours after admission Sherlock began passing his impaction and he was started on a mash diet. At 29 years old, Sherlock had strong opinions regarding what he should eat and he turned his nose up at EVERYTHING!! HE WANTED HAY!!

We did hand-graze Sherlock as much as possible, but at the end of October, there was little grass to be had and he needed some more nutrition!!

Sherlock and I finally came to a compromise....alfalfa cubes soaked with water. He ate it, begrudgingly.

As the days, then weeks, passed we were constantly trying to simplify things. Nasogastric intubation twice daily was hard on everyone. We started substituting the water in his mash for mineral oil. To my surprise, our picky patient began eating mashes containing 2 gallons of mineral oil each day! Simultaneously, the defect was beginning to fill with healthy granulation tissue and the packing was staying put for 2-3 days at a time. Fewer rectal exams made both Sherlock and the intern veterinarians happy! Eventually the defect became too shallow to retain the packing; however it was still quite large! It appeared to have stopped healing. So I did what I would do if the wound was on his leg...I debrided the granulation tissue in an attempt to stimulate healing. Every 2-3 days we gently "roughed-up" the surface of the granulation tissue. This really got things rolling and the defect very quickly decreased in size. We also gradually decreased the amount of mineral oil in Sherlock's mashes, trying to find the critical volume at which his manure remained soft enough not to cause a problem. We only needed ½ gallon a day drizzled on the dry alfalfa cubes!!

With Sherlock on autopilot we made plans to discharge him from WEC&H. On December 26th (10 weeks after admission) Sherlock left with Sara. Our only instructions were that Sherlock needed to continue to eat alfalfa cubes with oil. I re-evaluated him on the farm every 2-3 weeks until the tear healed. I followed up on the farm for the last time with Sara and Sherlock on February 1st, shortly after he celebrated his 30th birthday! He looked great and the rectal defect was no longer palpable. The oil had been gradually discontinued and then hay was gradually reintroduced. Today, Sherlock is a "normal" horse with a normal diet and routine. Sara has the green light to resume riding. This was truly one of those cases that presented several challenges and introduced me to a very special pair, Sara and Sherlock.